NY Attorney General Announces National Settlement With Anthem To End Pre-Auths For Opioid Addiction Drugs

January 20, 2017 – New York Attorney General Eric T. Schneiderman announced yesterday a settlement with Anthem, the second largest health insurer in the country, to end its policy of requiring prior authorization for medication-assisted treatment (“MAT”) for opioid use disorder. The agreement includes Empire BlueCross BlueShield (BCBS), which insures over 4 million New Yorkers, and the policy change will apply to most Anthem members in New York and nationally. This settlement comes months after Attorney General Schneiderman announced a similar agreement with Cigna to remove discriminatory barriers to MAT, and is the eighth agreement that AG Schneiderman’s Health Care Bureau has reached with health insurers who are not compliant with federal and/or NY State Parity Laws.

We applaud AG Schneiderman and his office for their continued leadership in enforcing the Parity Law and challenging discriminatory barriers to drug treatment. It is critical that all health insurers offer the full range of medications to treat substance use disorders, without imposing illegal barriers to these life-saving treatments.

Anthem/Empire BCBS required providers to submit a prior approval form for MAT coverage requests. In contrast, Empire BCBS does not require prior authorization for the majority of drugs it covers for medical conditions, including powerful opioids for the treatment of pain such as fentanyl, morphine, tramadol, and oxycodone. These disparities in authorization requirements are not consistent with the New York and federal mental health parity laws, which require health plans to cover mental health and substance use disorder treatment the same way they cover treatment for physical conditions.

The Attorney General’s investigation revealed that Anthem/Empire BCBS denied nearly 8% of the overall requests for coverage of MAT in 2015 and the first half of 2016. This subsequently caused significant delays in patients obtaining treatment for addiction – or patients never obtaining the treatment at all.

MAT, when prescribed and monitored properly, has proved effective in helping patients recover from opioid use disorder, and is both safe and cost-effective to reduce the risk of overdose. AG Schneiderman notes in the press release, “We’re facing an opioid crisis in New York and around the country – and we should be doing whatever we can to make lifesaving treatments accessible to those suffering from addiction.”

Under the agreement, Empire BCBS will also launch an initiative to expand access to MAT for members in its New York service area. Empire BCBS will conduct provider outreach and education regarding the benefits of MAT, informing qualified health care providers how they can obtain certification from the Substance Abuse and Mental Health Services Administration (“SAMHSA”) to prescribe buprenorphine and buprenorphine/naloxone as part of MAT for opioid dependence.

Through legal services and litigation, policy advocacy, technical assistance, and education, the Legal Action Center fights to increase coverage for substance use services, including medication-assisted treatment (MAT). LAC fights for access to the full continuum of these services in the community and criminal justice system and for an end to discrimination against people with histories of addiction. Please click here to read LAC’s Policy Recommendations for Expanding Access to MAT.

The Legal Action Center worked successfully with the substance use disorder and mental health fields towards passage of the federal mental health and addiction parity law in 2008. Through our work co-leading the national Coalition for Whole Health, we have worked to secure strong federal rules for covering substance use disorder and mental health treatment at parity with other health benefits in order to ensure that the law is implemented effectively.

For more information about the agreement between the Attorney General and Anthem/Empire BCBS, see the Attorney General’s press release. For more information about the New York Attorney General’s parity enforcement efforts and recent settlement agreements with health insurers, see LAC’s summaries.

For additional information about the federal mental health and addiction parity law, see the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA)’s website, as well as the Legal Action Center’s Guide to the Federal Parity Law and the tools developed by the Coalition for Whole Health. New Yorkers with questions or concerns about the settlement, the mental health and addiction parity laws, or any other health care matters can also call the New York Attorney General’s Health Care Bureau Helpline at 1-800-428-9071. Health care providers and advocates in New York seeking guidance on their clients’ rights under parity laws can call the Legal Action Center’s Parity Hotline at 212-243-1313.

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